Mhsaa Physical Examination Form printable pdf download

Mhsaa Physical Examination Form

MHSAA PHYSICAL EXAMINATION FORM

PLEASE NOTE: MHSAA requires any person officiating games to have a current physician’s certificate on

file with the local assigner indicating that the official is in good physical health and physically qualified to

officiate games. The undersigned official, at his or her discretion, selects the certifying physician. MHSAA

assumes no responsibility whatsoever for the selection of the physician and/or the accuracy or

thoroughness of the physical examination procured by the official.

Officials injured prior to fulfilling an assignment, must disclose this information to the Assigning

Secretary. Failure to do so may result in the loss of future assignments. Additionally, you agree to abide

by the medical instruction or advice of any licensed physician representing an institution during the

conduct of a game, including advice that you discontinue officiating in the opinion of the physician on

site.

NAME OF OFFICIAL: ______________________________________

Physician Name:

I hereby certify that I have conducted a physical examination on the above-named person and in my

professional opinion; this person is in good physical health and physically qualified to officiate MHSAA

games.  Dated this ____day of ___________, 20___.

_________________________________________________________ Physician’s Signature

_________________________________________________________ Physician’s Address

Official’s Signature __________________________________________

Mhsaa Physical Examination Form